Coding Challenge: Pharyngitis in Urgent Care

Determine the correct evaluation and management (E/M) service code for this urgent care encounter:


Sore Throat: 24-year-old female who complains of a sore throat. Symptoms began 2 days ago. Pain is of moderate severity. Fever is absent. Other associated symptoms have included pain while swallowing, swollen glands, and feeling that her right tonsil is swollen. Fluid intake is good. There has not been contact with an individual with known strep. Current medications include ibuprofen.

Current Outpatient Medications:

  • norethindrone-ethinyl estradiol-ferrous fumarate (LOESTRIN-FE,MICROGESTIN-FE,JUNEL-FE,LARIN-FE) 1-20 MG-MCG per tablet 1 tablet, Oral, Daily
  • OTC Ibuprofen

No Known Allergies


BP 147/87 (BP Location: Left arm; Patient position: Sitting)  | Pulse 101  | Temp 99.5 °F (37.5 °C) (Tympanic)  | Resp 16  | Ht 5′ 5″ (1.651 m)  | Wt 250 lb (113.4 kg)  | LMP 08/24/2022  | SpO2 99%  | BMI 41.60 kg/m²

  • General appearance: Alert, cooperative and no distress, obese
  • Head: Normocephalic
  • Ears: Clear without erythema
  • Nose: Without congestion or drainage
  • Throat: marked erythema, tonsillar hypertrophy, 2+, exudates present and mucous membranes moist
  • Neck: Supple with mild tender bilateral anterior cervical nodes
  • Lungs: clear to auscultation bilaterally
  • Heart: normal, regular rhythm, S1, S2 normal, no murmur, click, rub or gallop
  • Skin: Skin color, texture, turgor normal. No rashes or lesions

Recent Results (from the past 14 hours)

  • POCT CoVid-19 nucleic acid
    • Collection Time: 08/24/22  9:52 AM
    • Negative
  • POCT Strep Nucleic Acid
    • Collection Time: 08/24/22  9:53 AM
    • Positive
  • Collection Time: 08/24/22 10:52 AM
  • Negative


Strep Pharyngitis, Primary: J02.0

Orders this encounter:

  • POCT CoVid-19 nucleic acid
  • POCT Strep Nucleic Acid


1.  Discussed diagnosis with patient. Stressed fluid hygiene hydration. Push comfort measures. Follow-up with PCP in 3 to 4 days if not improved or sooner if worsen.

2. Medication changes and new medications: Augmentin 875 mg BID for 10 days. OTC NSAID PRN pain.

3. Follow up in about 1 week, or if symptoms worsen or fail to improve, or with primary care provider.

CHALLENGE: What is the appropriate E/M code for this encounter?

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Last Updated on February 20, 2023

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